International Journal of Psychosocial Rehabilitation
IN THE WITHDRAWAL FROM OPIOIDS.
Darwin TELIAS, MD
Joram NIR-HOD. D.C.
Telias, D., Nir-Hod, J. (2000) Buprenorphine-ketorolac
vs. clonidine-naproxen in the
withdrawal from opioids.
International Journal of Psychosocial Rehabilitation. 5, 29-33.
Correspondence to be addressed to: Dr. Darwin
Telias, POBox 4600, Beer-Sheva, Israel, Tel. 972-7-6401702, Fax 972-7-6401622,
The authors analyzed the comparative results of two groups
of patients undergoing detoxification from opiates: one group received
a Clonidine-Naproxen protocol, and the other received Buprenorphine-Ketorolac.
Success rate of Clonidine-Naproxen (CN) was 81%. and success rate of Buprenorphine-Ketorolac
(B-K) was 73%, success defined as patients who finished detoxification
procedures and were drug-free at the end.
Despite the better results for the CN group, BK was muchabating the costs significantly.Buprenorphine doses used were lower
better accepted by patients. One of the advantages of the Buprenorphine
protocol was that it did not require close supervision and monitoring,
than average reported in literature, and the authors attribute this to
the concomitant use of Ketorolac.
The authors recommend the use of BK in order to increase
the number of patients asking for treatment. The addictive potential of
Buprenorphine is emphasized but also the misuse of Clonidine by patients
attempting at self detoxification is brought to attention.
The need for an effective and accepted method of opioid withdrawal
is ever increasing. Different methods have been tried, but none has proven
to be perfect (1), (2). One of the principal problems of most methods is
that they require hospitalization, and are consequently expensive. Other,
less expensive methods are not easily accepted by patients asking for withdrawal,
either because they are painful or because the side effects are undesirable.
Classical maintenance-detoxification methods, such as methadone detoxification,
are not accepted by both public and some institutions, due to the preconcepts
about methadone, although methadone detoxification seems to be the most
effective and less troublesome method for ambulatory detoxification (3).
A new concept on opiate detoxification with Clonidine has been developed
in Israel, called “house detoxification” (4). In this method, the patient
receives instructions about the use of Clonidine, and performs the detoxification
at home, under family surveillance.
Two varieties of this procedure are used: in the first, the family receives
specific instructions about the use of a digital sphygmomanometer and about
Clonidine doses the patient has to receive, and about blood pressure monitoring
which permits or does not permit to administer the Clonidine. At the end
of the procedure (usually from 7 to 10 days) the patient returns to the
clinic for final check-up and directions for continuation of psychosocial
In the second variety, a team composed of a doctor and/or nurse, social
worker and counselor visit the patient at home, check blood pressure and
advise about continuation of medication, while at the same time starting
the psychosocial intervention, which is later continued.
We developed a different protocol for ambulatory detoxification, using
a combination of Buprenorphine and Ketorolac, to be used as the first variety
described above, and which was well accepted by patients.
MATERIAL AND METHODS
In an attempt to establish the comparative efficacy of two relatively
inexpensive ambulatory methods, we studied the results of 32
patients who were given a Clonidine-Naproxen protocol according to the
first variety described, and 81 who were given a Buprenorphine-Ketorolac
protocol, also on an ambulatory basis. Patients on B-K did not have to
be monitored, and consequently the cost of the treatment was considerably
lower. The treatments were carried out at a private clinic in Tel Aviv.
Initial daily doses of Buprenorphine were in average lower than generally
recommended, (5), (6), (7), and, in our opinion, this was possible due
to the use of Ketorolac.
The use of Ketorolac together with Buprenorphine was suggested by the
paper by CANADEL.-CARAFI. J. et al. (8). and it was based upon the rationale
that providing the patient with two different analgesics: an opioid one
(Buprenorphine). and a non-opioid one (Ketorolac) would greatly improve
the degree of analgesia, thus making the treatment more symptom-free.
Data for the two groups was as follows:
GROUP 1 (BUPRENORPHINE-KETOROLAC, BK) N = 82
Average age: 32 (range: 22-47)
Reported average daily use of Heroin: 0.84 grams
Average length of treatment: 9.75 days
Average initial dosage of Buprenorphine: 1.80 mgs/day
Succeeded: 60 (73%) (*)
GROUP 2 (CLONIDINE-NAPROXEN, CN)
N = 32
Average age: 32 (range: 24-49)
Reported average daily use of Heroin: 1.18 grams.
Average length of treatment: 9.5 days
Average initial dosage of Clonidine: 900 micgr/day
Succeeded : 26 (81%) (*)
* – Success defined as percentage of patients who finished
treatment and were detoxified at the end.
Buprenorphine – Ketorolac clonidine – naproxen Number 82 32 Average age 32 (22-47) 32 (24-49) Daily use of Heroin 0.84 grams 1.18 grams Average length of treatment 9.75 days 9.5 days Average initial medication dose 1.80 mgs./day 900 micgr/day Succeeded (% of patients who finished
N = 60 (73%) N = 26 (81%)
From the above it seems clear that success rate of Clonidine-Naproxen
(CN) is higher than that of Buprenorphine-Ketorolac (BK).
Nevertheless, there are other considerations to the problem:
First of all, we should consider the problem of logistics. The use of
Clonidine requires frequent blood-pressure check-ups, which are not easily
carried out at home. There is usually a need to either send a nurse home
to check blood pressure, or to provide the patients and/or their families
with a digital sphygmomanometer for self use. Not every patient can afford
a digital sphygmomanometer. Sphygmomanometers, when given to take home,
have a tendency to disappear or malfunction. With this method, families
are required to cooperate in a degree higher than generally accepted by
them, and not all families are ready to provide such a degree of cooperation.
Consequently not all patients may use this method.
In second place, we have to consider that CN has good, but not excellent
results in preventing the symptoms of withdrawal (9, 10), and patients
more often than not complain of pain and other symptoms of the withdrawal
syndrome, not entirely suppressed by either Clonidine or Naproxen. Many
patients refuse to start this method, because they have heard, or know
from previous experience, that symptoms are not totally avoided.
In third place there is the fact that in the first few days of CN patients
are usually unable to function properly, they have to lose working days
and give explanations as to why they were absent. In the cases when the
patient was working despite the addiction, this is undesirable.
Using BK allowed the patients to function normally since the first day
of treatment, thus avoiding social and labor problems.
This condition apparently enticed many addicts to come for treatment
who had never dared to do so before.
Although the Clonidine-Naproxen protocol was more effective than the
Buprenorphine-Ketorolac one, the authors are of the idea that the Buprenorphine-Ketorolac
protocol is more attractive for the patients, and entices them to come
for treatment more often and more willingly than the Clonidine-Naproxen
In places where the problem is to make treatment attractive, so as to
reach more potential patients and bring them forward, the use of the Buprenorphine-Ketorolac
protocol is advisable.
Nevertheless, it must always be taken into consideration that Buprenorphine
poses a risk for addiction, although lower than Morphine (11), (12), and
the use of Buprenorphine has to follow all the restrictions concerning
the use of any other addictive substance.
Clonidine, on the other hand, is not considered addictive in itself.
The authors could not find literature concerning the illegal or irrestricted
use of clonidine.
Despite the lack of literature on the subject, though, many patients
report having used Clonidine freely and without medical supervision, in
attempts at self-medicated withdrawal from opioids.
The irrestricted use of Clonidine seems to have been connected with
some deaths among the drug-addicted population in Israel, and consequently
also Clonidine use should be closely supervised and restricted.
(I) – KOSTEN,T.R: Current pharmacotherapies for opioid
dependence. Psychopharmacol.Bull. 1990; 26 (1): 69-74.
(2) – STINE, S.M.; KOSTEN, T.R,: Use of drug combinations
in treatment of opioid withdrawal.- J.Clin.Psychopharmacol. 1992 Jun; 12
(3) : 203-9.
(3)- SAN, L.; CAMI, J.; PERI, J.M.; MATA, R.;
PORTA, M.- Efficacy of clonidine, guanfacine and methadone in the rapid
detoxification of heroin addicts: a controlled clinical trial, – Br. J.
Addict. 1990 Jan; 85 (1): 141-7.
(4)- TELIAS, D.; SHERPSKY, I.; LUV. M.-
The Beer-Sheva project.- Vth International Congress on Drugs and Alcohol,
Jerusalem, March, 1991.
(5)- JOHNSON, R.E.; JAFFE, J.H.; FUDALA, P.J.:
A controlled trial of buprenorphine treatment for opioid dependence. –
JAMA. 1992 May 27; 267 (20): 2750-5.
(6)- KOSTEN. T.R.; MORGAN, C.; KLEBER, H.D.:
Treatment of heroin addicts using buprenorphine. – Am,J. Drug-Alcohol-Abuse.
1991Jun; 17 (2):119-28.
(7)- LANGE, W.R.; FUDALA, P.J.; DAX, E.M. .: Safety and
side-effects of buprenorphine in the clinical management of heroin addiction.
– Drug-Alcohol-Depend. 1990 Aug; 26 (1): 19-28.
(8)- CANADELL-CARAFI, J.; MORENO-LONDONO, A.; GONZALEZ-CAUDEVILLA,
B. – Ketorolac, a new non-opioid analgesic: a single-blind trial versus
buprenorphine in pain after orthopaedic surgery. Curr. Med. Res. Opin.
1991; 12(6): 343-9.
(9)- GUTHRIE, S.K.: Pharmacologic interventions for the
treatment of opioid dependence and withdrawal. DICP. 1990 Jul-Aug; 24 (7-8):
(10) – GOSSOP, M.; Clonidine and the treatment
of the opiate withdrawal syndrome. Drug Alcohol Depend. 1988 Jul;
(11) – SAN, L.; CAMI. J.; FERNANDEZ, T,; OLLE,
JM.; PERI, JM.; TORRENS,M. – Assessment and management of opioid withdrawal
symptoms in buprenorphine-dependent subjects. Br.J.Addict. 1992 Jan; 87(1):
(12) – FRISCHER, M. – Estimated prevalence of injecting
drug use in Glasgow.- Br.J.Addict. 1992 Feb; 87(2): 235-43.
Copyright © 2000, Southern Development Group,
S.A. All Rights Reserved.
A Private Non-Profit Agency for the good of all,
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Opiates, originally derived from the poppy plant, have been around for thousands of years. People use opiates for both recreational and medicinal purposes. Some opiates come from the raw, natural opium. While other opiates are manufactured to have the same chemical structure as the raw opium.
Opiates include a variety of drugs ranging from legal drugs such as fentanyl, codeine, and morphine to illegal drugs such as heroin. The one thing they all have in common is the ability to depress or slow down the body’s central nervous system.
There are three classifications of opiates. The first group is a naturally occurring opium derivative including morphine. The second group contains partially synthetic derivatives of morphine called opioid drugs such as hydrocodone, oxycodone, and oxymorphone. The third group contains synthetic compounds like Fentanyl, alfentanil, levorphanol, Meperidine, methadone, codeine, and Propoxyphene.
Natural Opiate Drugs
Natural opioids, as their name implies, come from a natural source known as the opium poppy plant. While some opioid drugs are completely manmade and manufactured in a lab, natural opiates come directly from this plant and the milk that comes from its seedpods. Though they are often thought to be less harmful than synthetics, they can still become addictive and cause dangerous respiratory depression.
Throughout history, opium was used as an anesthetic and remedy for nervous disorders, cancers, and migraines, among other conditions. Morphine, prescribed as a pain reliever, is a natural opiate, but is frequently used to illegally to get high.
Much like opium, synthetic opiates act on the same areas of the brain as opium and produce many of the same effects. Synthetic opiates are man-made, and offer treatment therapies for opiate addiction. They are created using chemicals not found in the poppy plant or from morphine or opium. The actual chemicals used vary from drug to drug and chemist to chemist.
Heroin, the most abused opiate drug, is a semisynthetic opiate derived from morphine. Drugs like heroin and OxyContin are often included with opiates. Although, they are actually considered semisynthetic opioids because they are derived from other naturally occurring opiates.
Semisynthetic opiates, developed as a safer alternative, have most of the same side effects as other opioid medications. Both synthetic and natural opium alkaloids are involved in the production of semisynthetic opiates.
Some of the most common opiates include:
According to statistics compiled by the Foundation for a Drug Free World , more than 13 million people worldwide use opium. Opium has the appearance of black or brown tar and commonly smoked by the individual. Made from the white liquid found in poppy plants, opium is one of the most expensive opiates in the world and is attractive to many addicts drawn to the powerful nature of the drug.
One of the most dangerous drugs in the world, heroin claims countless lives each year. Heroin can be snorted, smoked, or injected. While all three methods are dangerous, injection is by far the most dangerous, as individuals who share dirty needles with other users after injecting heroin are at a high risk for contracting HIV/AIDS or Hepatitis.
Many people abusing heroin do not realize it is an opiate. Processed from morphine, this street drug has taken many lives over the years.
Sometimes referred to as “Hillbilly Heroin”, OxyContin has proven to be a problem for addiction treatment professionals and emergency room workers alike. OxyContin is a prescription painkiller like Vicodin, but the drug is a time-release medication –designed to distribute its active ingredients over time. Problems arise when individuals begin snorting or injecting the addictive drug, allowing them to inject all of the opiates at once – thus putting themselves at risk for overdose and illness.
This opiate is known as a narcotic analgesic. It can be successfully used to relieve pain. Hydrocodone is a prescription drug that is sold as Vicodin, Lorcet, Lortab and other name brand prescription painkillers.
An opiate drug, hydrocodone is highly addictive. While not everyone with a hydrocodone prescription will develop hydrocodone addiction, most will become physically dependent on the drug. This prescription drug is used to treat pain, but has also become popular on the street.
According to the World Health Organization , Codeine is the most widely and commonly used opiate in the world. It is usually administered orally and has a reputation of being the safest of all the opioid analgesics.
However, this can be misleading since many individuals become physically dependent on the drug after extended and repeated use. The most common medical use of Codeine is used to suppress chronic coughing. Almost all cough syrups in the United States that require a prescription contain Codeine.
The most active substance in opium is morphine—named after Morpheus, the Greek god of dreams. Morphine is a very powerful painkiller, but it is also very addictive. Morphine is prescribed by doctors for the treatment of serious pain. Unfortunately, many people have come to abuse this drug illegally, as they enjoy the effects it has on their body.
Methadone has been growing in popularity since the 1940’s, at which time it was synthesized from methadone due to a morphine shortage. It may not share the same chemical characteristics as heroin and morphine, but the end result is oftentimes the same. In today’s world, methadone is commonly used for the treatment of a narcotic addiction, however, many people become addicted to this drug due to the way it makes them feel.
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